Saturday, October 27, 2012

USA Triathlon Fatality Incidents Study Released

The USA Triathlon Fatality Incidents Study was released this week.

USA Triathlon is the National Governing Body for the sport in the United States. Due to the number of deaths in the sport in the recent past, it convened a panel to objectively review the event-related fatalities.

Over the past several months, USA Triathlon conducted a review of the collective experience with fatalities at USA Triathlon-sanctioned events from 2003 through 2011. Its goals were to bring clarity, identify potential patterns and underlying causes, and investigate opportunities to make any future improvements in event safety.

Its five-member Medical Review Panel included 3 physicians and 2 race directors with broad experience in triathlon, and interest or expertise in the issue of race safety. This group reviewed information for 45 cases and assembled its findings into a preliminary report.

The preliminary report was shared first with the attendees of the USA Triathlon Race Directors Symposium in January 2012 as well as a Review Group that included the editorial staff of the Daily News of Open Water Swimming and representatives from the broader triathlon community—athletes, coaches, event organizers, risk management experts, and medical professionals.

The information on each fatality included the individual's age, gender, and the name, date, format, and length of the USA Triathlon event, as well as a brief narrative of the circumstances of the fatality and press accounts of the fatalities.

But the information that was not available for review included a detailed medical history of the viction (i.e., medical conditions), a detailed accounts of medical treatment(s) provided at the event or during/after transport to the hospital, official autopsy findings, if any, experience level with triathlon or endurance sport in general, the safety plan in place for the event, medical resources on site for the event, and the water temperature and conditions during the swim leg. In some cases, limited second-hand information about victim’s medical history, medical treatment, and autopsy findings were available, but the panel recognized this information may not be accurate or complete.

USA Triathlon provided some good baseline information on the sport's popularity in this period of view (2003-2011): nearly 23,000 sanctioned events involved more than 3 million participants with 4,334 events involving 537,317 participants in 2011 alone.

Of the 45 fatalities, 9 were women and 35 were men ranging in age from 24-76 for an overall fatality rate for triathletes of approximately 1 per 76,000 participants.

- 5 deaths were traumatic, caused by injuries sustained in cycling crashes
- 38 deaths were non-traumatic
- 30 deaths occurred during the swim
- 3 deaths occurred during the bike
- 3 deaths occurred during the run
- 2 deaths occurred after an athlete had completed a race
- 1 death was of a non-athlete spectator who died from bike crash injuries
- 1 death was at a USA Triathlon training clinic

Of the 31 swimming-related deaths, 1 athlete died during a quarter-mile swim at a triathlon clinic due to cardiac arrest. The remaining deaths occurred in races that took place from March to November of various distances from 400 yards to 2.4 miles.
4 victims were relay swimmers; 26 victims were individual racers.

5 deaths were in the ocean; 13 in a lake; 6 in a bay or gulf; and 6 in a river.

3 had time-trial starts (with participants starting individually at 2-5 second intervals); 2 had mass starts; and 25 with wave starts with a range of 40-150 athletes per wave.

Complete information about wetsuit use by the victims was not available.

The vast majority of the victims was rescued from the water and received CPR and advanced life support measures at the scene. In two cases, there was a delay of up to several hours before the missing participants were found. In these cases the victims were pronounced dead at the scene.

Detailed autopsy information was not available for review, although available data indicates the swimming fatalities appear to be caused by episodes of sudden cardiac death (SCD).

Background on SCD

There are an estimated 4,300 sports-related SCDs in the U.S. annually, according to a recent scientific report published by the American Heart Association. These occur during all forms of athletic activity. According to a recent scientific report in the New England Journal of Medicine, most, but not all, episodes of SCD are thought to be due to an underlying, often unrecognized, abnormal heart conditions such as hypertrophic cardiomyopathy (HCM) or coronary artery disease. The treatment for sudden cardiac arrest is prompt bystander CPR, early defibrillation (within a few minutes), and follow-up hospital care. Even with prompt medical attention the survival rate for sports-related sudden cardiac arrest remains low, at 10-25%.

Studies indicate that triathlon’s rate of 1 fatality per 76,000 participants is similar in comparison to the sport of marathon running. A 2010 study on the London Marathon cited one fatality for every 67,414 runners over a 20-year period. A 2008 study examined the Twin Cities and Marine Corps Marathons and cited one fatality for every 75,000 runners since 1976.

Key Findings of the report included the following:

1. The fatality rate did not increase as a trend between 2003-2011. However, the total number of deaths increased as the total number of participants increased.

As the sport continues to grow (USA Triathlon annual membership more than tripled between 2003 and 2011), the incidence of fatalities in the sport will likely increase as well.

2. The fatality rate does not appear to be related to the length of the race, the type of swim venue, or the method of swim start (e.g., mass, wave or time trial).

3. The victims appear to have included athletes from a broad range of triathlon experience. Fatalities were not confined to inexperienced triathletes.

As it relates specifically to SIPE, recently a popular theory for cause of death in these cases, we recognize this clinical syndrome and the difficulties of establishing this diagnosis clinically or at autopsy. It is known from scientific reports that this syndrome affects swimmers and divers with progressive shortness of breath and low levels of oxygen in the blood—symptoms that resolve completely with cessation of swimming and removal from the water.

Although USA Triathlon cannot exclude the possibility of a role for SIPE in the victims’ deaths, it knows of no victim with an antecedent diagnosis of SIPE and it found no information in its review that would establish this diagnosis with certainty in the victims.

2 comments:

Steve, et al,After many years as a race director for Canada's largest open water swim event, and holding the fort as a co director of the IMC medical tent, I findthis is a useful review that, regrettably, does not get us any closer to narrowing down the primary risk factors that might be identifiable and modifiable prior to racing. Regardless, there may still be value to wave starts, encouraging good training and medical screening, open water experience, and warmup prior to racing, as well as appropriate seeding in races.It is too bad that wetsuit info was not available, as it might continue to be a useful life preserver as a flotation device, perhaps reducing some risks when swimmers are wetsuited.It may have been interesting to hear about water/wave conditions, or water temperature, as well as whether starts had gun versus a quiet start (an adrenaline effect?). And what the athlete may have injected prior to starting the race--caffeine? excess food? Other supplements?Finally, it is of course frustrating to understand the limitations of autopsy, since cardiac arrhythmias escape detection, and the athlete can no longer tell the examiner what happened, including simply the accidental ingestion of water during the swim. For this reason, it may be useful to collect data on the swimmers that were successfully pulled out of the water prior to a potentially fatal event, to get their stories (I assume there have been some successful rescues over the years!). Greg Welch's story comes to mind as one example.For us in the medical support of these kinds of races, regular updates and improved data collection will remain vital in the quest to ultimately eliminate this unfortunate recurrance.

You bring up excellent points that may never be solved. Out of respect to the victim's family, and due to various legal considerations, information surrounding the conditions of a death are not provided by the race director or the local authorities. Therefore, there is no detailed or comprehensive data collection by any governing body or entity in order to enhance the knowledge surrounding these tragedies, at least in the open water swimming world.

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